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2023 Benefits summary
Benefits schedule for the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
All non-emergency specialty and hospital services require a prior referral from your PCP. Call member services to inquire if a referral is required prior to the services being rendered.
|
Type of Service or Supply |
Benefit Level |
|
Lifetime Maximum |
No lifetime maximum |
|
Individual Annual Out-of-Pocket Maximum (Includes Pharmacy) |
$3,000 |
|
Family Annual Out-of-Pocket Maximum Includes Pharmacy) |
$6,000 |
|
If a retiree and one or more eligible family members are covered under this option, after one covered family member meets the individual out-of-pocket maximum, benefits for that individual are payable at 100% by the Plan. Once the family meets the family out-of-pocket maximum, benefits for all covered family members are payable at 100%. |
|
|
Preventive Care |
|
|
Preventive Care Office Visits |
No charge |
|
Routine Physicals & Immunizations |
No charge |
|
Well Woman Care (including Pap Smear Test) |
No charge (direct access / no referral) |
|
Mammograms |
No charge |
|
Well Baby Care (including Immunizations) |
No charge |
|
Prostate Cancer Screening |
No charge |
|
Primary Care |
|
|
PCP Office Visits – Including Telemedicine |
$25 copay per visit |
|
Allergy Treatment- Routine injections at PCP’s office, with or without physician encounter |
$25 copay per visit |
|
Hearing Aids |
Not covered (See Exclusions section for information about the Amplifon Hearing Health Care (formerly HearPo) Discount Program and the Hearing Care Solutions Discount Program) |
|
Specialty And Outpatient Care |
|
|
Specialist Office Visits- Including Telemedicine |
$40 copay per visit |
|
Walk in Clinic (Retail Clinic) |
$40 copay per visit |
|
Prenatal Care (applies to standard global maternity services and initial visit) |
$40 copay per visit (no referral required) |
|
Maternity (childbirth/delivery services) |
90% coverage |
|
Allergy Testing |
$40 copay per visit |
|
Imaging (CT/PET scans, MRIs) |
90% coinsurance |
|
Diagnostic X-rays and Outpatient Labs associated with an office visit |
No additional charge |
|
Therapy (speech, occupational, physical) |
$40 copay per visit |
|
Chiropractic Care |
$40 copay per visit – 20 visits per calendar year |
|
Outpatient Rehabilitation |
$40 copay per visit |
|
Home Health Care |
90% coinsurance |
|
Skilled Nursing Care |
90% coverage |
|
Prosthetic Devices |
90% coinsurance |
|
To see a list of procedures that require precertification, please reference the National Precertification List* on the Aetna member website. |
|
|
Inpatient Services(Precertification required) |
|
|
Hospital Room and Board and Other Inpatient Services |
90% coverage |
|
Skilled Nursing Facilities |
90% coverage |
|
Hospice Facility |
90% coverage |
|
Surgery and Anesthesia |
|
|
Inpatient Surgery |
90% coverage |
|
Outpatient Surgery |
90% coverage |
|
Behavioral Health and Substance Use Disorder Treatment |
|
|
Office Visit |
$25 or $40 copay per visit |
|
Outpatient Services |
90% coverage |
|
Inpatient Treatment (including residential treatment centers) |
90% coverage |
|
Urgent and Emergency Care |
|
|
Urgent Care |
$60 copay per visit |
|
Emergency Room |
$150 copay (waived if admitted) |
|
Ambulance |
90% coverage |
|
Prescription Drugs through Express Scripts(No annual maximum benefit) |
|
|
Annual out-of-pocket maximum |
Combined with medical out-of-pocket maximum |
|
Short-term (30-day supply)* ** |
$15 copay – generic formulary drugs |
|
Long-term (90-day supply)* |
$30 copay – generic formulary drugs |
^ National Precertification List on the Aetna member website
* If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the full difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum.
** A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition or blood pressure. After the third short-term fill of a maintenance medication, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.
*** Formulary means Express Scripts’ formulary of preferred prescription drugs.
Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance and is included in the drug list linked here, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.